Download Smear positive pulmonary tuberculosis among Northeast Ethiopia

Amare et al. Infectious Diseases of poverty 2013, 2:6
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RESEARCH ARTICLE
Open Access
Smear positive pulmonary tuberculosis among
diabetic patients at the Dessie referral hospital,
Northeast Ethiopia
Hiwot Amare1*, Aschalew Gelaw2, Belay Anagaw2 and Baye Gelaw2
Abstract
Background: Tuberculosis (TB) is an infectious disease which is still a major cause of morbidity and mortality
throughout the world. People with diabetes mellitus (DM) have a three times higher risk of developing active TB
than people without diabetes. However, there is not enough credible information on the burden of pulmonary
tuberculosis (PTB) among DM patients in Ethiopia, in general, and in the city of Dessie, in particular. Therefore, this
study aims to determine the prevalence and associated risk factors of smear positive PTB among diabetic patients
at a referral hospital in Dessie.
Methods: A cross-sectional study was conducted from February 2012 to April 2012. Patient demographic
characteristics were collected using a pre-tested standard questionnaire format. Spot-morning-spot sputum
specimens were collected from the study participants and examined for acid-fast bacilli using direct microscopy by
the Ziehl-Neelsen staining technique. Data was entered and analyzed using the SPSS version 16 statistical software
and p-value <0.05 was considered as statistically significant.
Results: Out of 225 TB suspected diabetic patients, 52% were males and 48% were females. Their ages ranged from
12 to 82 years, with a mean age of 47.2 years. Urban residence (AOR: 5.5; 95% CI: 1.07–28.20), history of TB (AOR:
13.4; 95% CI: 2.74–65.73), contact with TB patients in the family (AOR: 9.4; 95% CI: 1.822–48.50), and long duration of
DM (AOR: 8.89; 95% CI: 1.88–58.12) were independently associated with the development of active TB in people
living with DM.
Conclusions: The prevalence of smear positive PTB was 6.2% in TB suspected diabetic patients, which is higher
compared with the general population (0.39%). Patients with a previous history of contact with TB patients, as well
as those who had prolonged diabetes, were more prone to have PTB. Therefore, screening of diabetic patients for
PTB infection during follow-up is necessary.
Keywords: Dessie, Diabetic patients, Ethiopia, Pulmonary tuberculosis (PTB)
Multilingual abstracts
Please see Additional file 1 for translations of the abstract into the six official working languages of the
United Nations.
Background
Tuberculosis (TB) is an infectious disease caused by
various strains of mycobacteria, especially Mycobacterium tuberculosis and usually attacks the lung [1]. It
* Correspondence: [email protected]
1
Bahir Dar Regional Health Research Laboratory Center, Bahir Dar, Ethiopia
Full list of author information is available at the end of the article
remains to be a major cause of morbidity and mortality
throughout the world. It is estimated that one-third of the
world's population is infected, 8.8 million people develop
TB, and 1.45 million people die annually from the disease
[2]. In Africa, about 2.8 million incident TB cases and 390
thousands TB deaths occurred in 2009 [3]. Ethiopia ranks
seventh among the world’s 22 high-burden TB countries
[2]. According to the World Health Organization’s
(WHO) Global TB Report 2011, Ethiopia had an estimated incidence rate of 261 cases per 100,000 population
and 29 thousands deaths in 2010, with an estimated prevalence rate of 394 cases per 100,000 population [2]. The
© 2013 Amare et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Amare et al. Infectious Diseases of poverty 2013, 2:6
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incidence of TB was reported greatest among people with
impaired immunity, HIV infection, or diabetes [4].
Diabetes mellitus (DM) is complex metabolic disorder
that is characterized by a high level of blood sugar either
because the body does not produce enough insulin or
cells do not respond to the insulin [5]. This high level of
blood sugar produces the classical symptoms of frequent
urination, and increased thirst and hunger. The total
number of people with DM worldwide is projected to
rise from 285 million in 2010 to 439 million in 2030 [4].
In 2010, 12.1 million people were estimated to be living
with diabetes in Africa, and this is projected to increase
to 23.9 million by 2030 [6]. The WHO estimated that
the number of cases of diabetes in Ethiopia was about
800,000 in 2000, and projected that it would increase to
about 1.8 million by the year 2030 [7].
Besides HIV, malnutrition, alcoholism, and smoking,
DM has received recent recognition as a risk factor for TB
[8]. Epidemiological studies have elucidated an association
between DM and the development of TB [9]. According
to a study done by Jeon CY et al., people with DM had approximately a three times higher risk of developing TB
than people without diabetes, and this has been evidenced
by biological support of the causal relationship between
diabetes and host immunity to TB [10]. Evidence from an
experimental study revealed that diabetes was associated
with reduced macrophage functions, such as chemotaxis,
phagocytosis, and bactericidal actions, and also impairs
the function and proliferation of T-helper 1 cells and their
production of cytokines [11].
On the other hand, a study done in Brazzaville, Congo
showed that TB patients with diabetes were more likely to
have an increased rate of treatment failures, deaths, defaults and relapses, delayed smear, and culture conversion
[12]. It was also found that TB treatment reduced the effectiveness and concentration of diabetes medications,
which makes it difficult to control diabetes [13]. However,
the prevalence of PTB among diabetic patients was not
assessed in the study area. Therefore, this study was
conducted to determine the magnitude of smear positive
PTB and its associated risk factors among TB suspected
diabetic patients at the Dessie referral hospital.
Methods
Study design and period
A cross-sectional study was employed to assess the
prevalence and associated risk factors for the occurrence
of PTB among TB suspected diabetic patients from
February 2012 to April 2012.
Study area and participants
The study participants were recruited from the Dessie
referral hospital. Dessie is located in the northeast part
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of Ethiopia in the South Wollo administrative zone of
the Amhara Region, which is 401 km away from the capital city, Addis Ababa. This referral hospital provides services to the population in the surrounding area of the
town and the adjacent regions. In this study, 225 TB
suspected diabetic patients who visited the Dessie referral hospital during the study period were included.
Sample size and sampling technique
The sample size was determined using a single population
proportion formula, n = z2p (1-p)/ w2, where n = sample
size, Z = standardized normal distribution value at the
95% CI, which is 1.96; P = the proportion of TB sufferers
among diabetics from a previous study conducted at Addis
Ababa, 5.8% [14], and w = the margin of error, taken as
3%. Since the average total number of diabetic patients
who visited the Dessie referral hospital for follow-ups was
approximately 1,700 (i.e. < 10,000), the required maximum
sample of 205 was obtained from the above estimate by
making some adjustments. The final sample size was determined to be 236 after calculating that nf = n/1 + (n/N)
and by taking into account a 15% non-response rate.
Sampling technique
All pulmonary tuberculosis (PTB) suspected diabetic patients who visited the Dessie referral hospital during the
study period were included until the required sample
size (236) was obtained.
Data collection tools
Administration of questionnaire
Information concerning patients' socio-demographics
and associated factors was collected by trained nurses
using a pre-tested standard questionnaire during the
study period.
Specimen collection and laboratory investigation
Diagnosis of smear positive PTB among TB suspected diabetic patients were done based on the national TB diagnosis guidelines. All laboratory investigations were done
adhering to accepted standard procedures. Three consecutive sputum samples (spot-morning-spot) were collected,
smeared, and stained with the Ziehl-Neelsen staining
method. The stained smears were then examined under
the oil immersion objective to look for acid-fast bacilli in a
light microscope.
As a quality control method, all new lots of reagents
were tested with known positive and negative control
slides, and then all the positive and 10% of the negative
slides were re-read by experienced laboratory technologists who were bind for the smear for confirmation. Pulmonary TB is diagnosed if at least two smear results are
positive for AFB or one sputum specimen is positive with
additional x-ray abnormality [15]. Fasting blood glucose
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was measured by a photometer and a glucometer based
on the procedure supplied by the manufacturer.
Data processing and analysis
The data was entered and analyzed using the statistical
package for social sciences (SPSS) version 16 statistical
software. Odds ratios (OR) and their 95% confidence intervals (CI) were estimated using bivariate and multivariate
logistic regression analysis to identify possible explanatory
variables on occurrence of PTB. The result at p-value
<0.05 was considered as statistically significant.
Ethical considerations
Before starting the study, ethical clearance was obtained
from the ethical review committee of the School of Biomedical and Laboratory Sciences, University of Gondar.
Informed consent was also obtained from the Dessie referral hospital and the study participants. The confidentiality of the information collected was maintained by
using code numbers for participants. In addition, the
clinical specimens collected during the study period
were used for the stated objectives. For those participants who were positive for PTB, appropriate treatment
was prescribed by physicians and health education was
given to prevent spread of the infection to others.
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duration of DM in all patients varied from one year to
30 years, with a mean duration of 5.6 ± 4.4 years. More
than half of the respondents (132) had DM for less than
five years (58.7%). The body mass index (BMI) of the TB
suspected diabetes patients showed that 141 respondents
(62.7%) were normal (18.5–24.99 kg/m2), 30 (13.3%)
were underweight (<18.5 kg/m2) and 54 (24%) were
overweight (≥25 kg/m2) (see Table 2).
Prevalence of pulmonary tuberculosis among diabetic
patients
Out of the 225 TB suspected diabetic patients, Mycobacterium tuberculosis was detected in 14 of the diabetic patients
(11 males and three females) by direct microscopy, and
supported by chest x-ray. Therefore, the overall prevalence
of smear positive PTB was 6.2% in the study population. In
addition, five (35.7%) of these TB-diabetic patients were
also infected with HIV.
A relatively higher proportion of PTB was observed
among the age group of 40 years and over [64.3% (9/14)],
in male respondents [78.6% (11/14)], and in urban dwellers
[78.6% (11/14)]. Data on marital status showed that 64.3%
(9/14) of PTB positive patients were married, 28.6% (4/14)
were divorced or widowed, and the rest were single. Most
of the PTB patients were also employed 42.8% (6/14). Most
of the TB-diabetes patients had type 2 diabetes 78.6%
(11/14) and type 1 diabetes accounted for 21.4% (3/14).
Results
Socio-demographic characteristics of tuberculosis
suspected diabetic patients
A total of 236 TB suspected known diabetic patients were
expected to be enrolled in this study. However, 11 (4.7%)
respondents who were unable to bring sufficient sputum
for investigation were excluded. As a result, this study had
a response rate of 95.3%. Of the 225 study participants,
116 (51.56%) were males and the mean age was 47.2 years
(ranging from 12–82 years). The majority (147) of the participants (65.4%) were above the age of 40. More than half
the respondents (144) were married (64%) and 139 were
urban dwellers (61.8%). In terms of literacy, 141 of the respondents (62.7%) were illiterate and just completed elementary school; and the rest either completed high school
or higher education. Regarding occupational status, 77 respondents (34.22%) were employed (government or private), 61 were merchants (27.1%), 61 were farmers
(27.1%), and the remaining 26 (11.6%) were laborers. The
monthly income of 67 respondents (29.8%) was less than
US 23 dollars, followed by 56 respondents (24.9%) who
earn US 38–67 dollars (see Table 1).
Coughing was the most common symptom, with all
the respondents reporting this symptom. This was
followed by 220 respondents reporting sputum production (97.8%), 104 had loss of appetite (46.2%), 72 had
night sweating (32%), and 54 had chest pain (24%). The
Risk factors associated with pulmonary tuberculosis
Bivariate logistic regression was used to identify possible
explanatory (independent) variables and those variables,
which have a p-value of less than 0.20, were taken to
multivariate logistic regression. As a result, place of residence (P = 0.041), religion (P = 0.049), past history of TB
(P = 0.001), presence of TB patients in the family
(P = 0.012), and duration of diabetes (P = 0.008) were significantly associated with the occurrence of PTB
(see Table 3). On the other hand, age (P = 0.811), sex
(P = 0.103), educational status (P = 0.619), occupational
status (P = 0.659), marital status (P = 0.921), monthly income (P = 0.666), blood glucose level (P = 0.267), smoking
(P = 0.410), BMI (P = 0.463), and consumption of alcohol
(P = 0.466) were not significantly associated with development of PTB.
Urban dwellers were about six times (AOR = 5.5; 95%
CI = 1.07–28.20) more likely to develop PTB than rural residents. Respondents who had a previous history of TB were
also 13 times (AOR = 13.4; 95% CI = 2.74–65.73; P = 0.001)
more likely to develop PTB than those who did not have a
previous history of TB. Regarding family history of TB,
those who had contact with TB patients were about nine
times (AOR = 9.4; 95% CI = 1.82–48.50; P = 0.007) more
likely to develop PTB than respondents who didn’t have
history of contact with TB patients (see Table 3).
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Table 1 Socio-demographic characteristics of tuberculosis suspected diabetic patients at the Dessie referral hospital,
from February to April 2012
PTB infection
Characteristics
Frequency (N = 225)
Negative n (%)
Positive n (%)
n (%)
Male
105 (90.5)
11 (9.5)
116 (51.5)
Female
106 (97.2)
3 (2.8)
109 (48.5)
18 (97.7)
1 (2.3)
19 (8.4)
Sex
Age (years)
≤20
21–30
19 (95.0)
1 (5.0)
20 (8.9)
31–40
36 (92.3)
3 (7.7)
39 (17.3)
41–50
55 (91.7)
5 (8.3)
60 (26.7)
>50
83 (95.4)
4 (4.6)
87 (38.7)
Christian
106 (97.2)
3 (2.8)
109 (48.4)
Muslim
105 (90.5)
11 (9.5)
116 (51.6)
Illiterate
74 (94.8)
4 (5.2)
78 (34.7)
Elementary school
60 (95.2)
3 (4.8)
63 (28)
Religion
Education level
Secondary school
32 (89)
4 (11)
36 (16)
Higher education
45 (93.7)
3 (6.3)
48 (21.3)
Single
41 (97.6)
1 (2.4)
42 (18.7)
Married
135 (93.7)
9 (6.3)
144 (64)
Divorced
17 (89.4)
2 (10.6)
19 (8.4)
Widowed
18 (90)
2 (10)
20 (88.9)
Marital status
Place of residence
Urban
128 (92)
11 (8)
139 (61.8)
Rural
83 (96.5)
3 (3.5)
86 (38.2)
71 (92.2)
6 (7.8)
77 (34.2)
Occupation
Employed *
Farmer
59 (96.7)
2 (3.3)
61 (27.1)
Merchant
59 (96.7)
2 (3.3)
61 (27.1)
Laborer
22 (84.6)
4 (15.4)
26 (11.6)
<23
64 (95.5)
3 (4.5)
67 (29.8)
23–38
46 (95.8)
2 (4.2)
48 (21.3)
Average monthly income (US dollars)
39–67
52 (92.9)
4 (7.1)
56 (22.7)
>68
49 (90.7)
5 (9.3)
54 (24.3)
* = employed by the government or privately.
Moreover, the duration of diabetes was independently
associated with PTB. The prevalence of PTB increased
progressively with the duration of DM (see Figure 1). High
prevalence of PTB was observed among the study population who had diabetes for more than ten years (2.7%)
followed by those who had diabetes for five to ten years,
and less than five years (2.2% and 1.3%, respectively).
Diabetic patients that had the disease for more than ten
years were nine times (AOR = 8.89; 95% CI = 1.88–58.12;
P = 0.025) more likely to develop PTB than those who
have lived with DM for less than five years.
Although, the BMIs and blood glucose levels of the respondents were not significantly associated with the development of PTB, relatively high prevalence of PTB was
Amare et al. Infectious Diseases of poverty 2013, 2:6
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Table 2 The patterns of pulmonary tuberculosis and
types of diabetes, body mass index, and blood glucose
levels of respondents at the Dessie referral hospital, from
February to April 2012
Characteristics
TB infection among patients Total (%)
Negative (%)
Positive (%)
Type 1
37 (92.5)
3 (7.5)
40 (17.8)
Type 2
174 (94.1)
11 (5.9)
185 (82.2)
<18.5
29 (96.7)
1 (3.33)
30 (13.3)
18.5–24.99
130 (92.2)
11 (7.8)
141 (62.7)
≥25
52 (96.3)
2 (3.7)
54 (24)
observed among TB suspected diabetic patients who had a
normal BMI (7.8%) and a blood glucose level greater than
288 mg/dl (14.3%). The prevalence of PTB among malnourished (<18.5 kg/m2) and overweight (≥25 kg/m2)
diabetes patients was 3.3% and 3.7%, respectively
(see Table 2).
Types of DM
Body mass index (kg/m2)
Blood glucose (mg/dl)
≤168
57 (98.3)
1 (1.7)
58 (25.8)
169–220
55 (96.5)
2 (3.5)
57 (25.3)
221–288
51 (94.4)
3 (5.6)
54 (24)
>288
48 (85.7)
8 (14.3)
56 (24.9)
Discussion
Previous studies have identified an important association
between diabetes and TB, in that DM is one of the risk
factors for the development of active PTB [8,9]. However,
in Ethiopia, particularly in Dessie, little is known about
prevalence and associated risk factors of PTB in the population of those with diabetes. Hence, the present study
tries to provide insights into the prevalence of PTB in diabetic patients, as well as outline some possible risk factors.
In this study, the prevalence of PTB among TB
suspected diabetic patients was 6.2%. It is higher than
the 2011 WHO estimated prevalence of TB in the general population of 0.39% [3]. This finding is in line with
Table 3 Association of socio-demographic characteristics and other risk factors with pulmonary tuberculosis in
respondents at the Dessie referral hospital, from February to April 2012
Characteristics
PTB infection
COR(95% CI)
AOR(95% CI)
P-value
11
3.7(1.04–13.65)
3.6(0.77–16.73)
0.103
3
1.00
1.00
−ve(n)
+ve(n)
Male
105
Female
106
Sex
Religion
Christian
106
3
1.00
1.00
Muslim
105
11
3.7(1.04–13.648)
5.03(1.13–22.42)
Urban
128
11
2.38(0.64–8.778)
5.5(1.07–28.20)
Rural
83
3
1.00
1.00
Yes
5
2
6.87(1.21–39.12)
No
206
12
1.00
Yes
20
6
7.16(2.26–22.72)
13.4(2.74–65.73)
No
191
8
1.00
1.00
0.034
Place of residence
0.041
Smoking
Past history of TB
0.001
Presence of TB patients in the family
Yes
23
5
4.54(1.40–14.72)
9.4(1.82–48.50)
No
188
9
1.00
1.00
129
3
1.00
1.00
0.007
Duration of DM
≤5 years
6–10 years
56
5
3.84(0.88–16.62)
4.01(0.48–16.43)
>10 years
26
6
9.92(2.33–42.24)
8.89(1.88–58.12)
−ve = negative.
+ve = positive.
0.025
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Positive
Negative
97.7
100
91.8
90
81.2
80
Percentage
70
60
50
40
30
18.8
20
10
8.2
2.3
0
<5 years
5-10 years
>10 years
Duration of diabetes mellitus in years.
Figure 1 Prevalence of smear positive pulmonary tuberculosis compared with the duration of diabetes mellitus in patients at the
Dessie referral hospital, from February to April 2012.
the reports from Tanzania (5.4%) and India (6%) [16-18].
However, the finding of the current prevalence of PTB
among diabetics was higher than the prevalence
reported in Korea (2.12%) [19]. On the other hand, the
burden of PTB in Dessie was lower than the prevalence
reported from Pakistani studies that revealed the prevalence of PTB to be from 9.5% to 14% among diabetic
patients [20-22]. This variation could be due to the use
of an advanced diagnosis technique in Pakistani studies,
and the fact that the study participants were admitted
patients and thus were more likely to be positive.
A study done in Addis Abeba showed that 4.14% of diabetic patients had PTB, which is lower than the present
study finding [7]. The increased prevalence of PTB in our
study might be due the involvement of TB suspected
diabetic patients as compared to the study in Addis
Ababa, which was retrospective and considered all diabetic
patients.
The socio-demographic characteristics of PTB suspected
diabetic patients and other risk factors for active PTB
infection were also investigated. Several studies have
shown that socio-economic status is a risk factor for
active TB occurring [23-25]. The result of this study
showed that the higher the age of the patients, the more
likely it is that they will have TB infection if they are
also diabetic. The majority of the patients who developed
PTB were older than 40 years of age and this was comparable to other age reports from Indian, Korea, and
Pakistan [17,20,22]. The possible reason for this may be
due to a compromised host’s immunity that increased
susceptibility to TB due to aging, and most diabetic
patients were in the over 40 age group as well.
The association of sex with active PTB infection was
not statistically significant. However, among the 14 PTB
patients, 11 (78.6%) were male which indicates a higher
proportion of PTB infection among male diabetic patients
rather than females (21.4%). This result was consistent with
a study in Pakistan (78% versus 22%, respectively) [22].
Urban residence was also associated with the development of PTB. The prevalence of smear positive PTB in
this study was higher in urban dwellers (52.7%) than rural
residents. This finding was consistent with a study done in
India, in which the prevalence of smear-positive TB was
reported to be 69.2% [26]. The possible reasons for this
could be because of crowded living conditions in urban
areas, as well as urban dwellers having lower levels of
physical activity and mostly consuming a calorie rich diet,
which increases fat accumulation in the body. Physically
inactive or sedentary lifestyles lead to excess body fat accumulation which increases insulin resistance and ultimately
results in higher blood glucose levels which impairs the
immune cells against TB infection [23].
The role of smoking in the development of active TB
is well established [27], but smoking was not associated
with active TB in this current study and this could probably be attributed to a social desirability bias whereby
smokers denied their smoking status.
This study also identified the variable that has the
most important influence on the occurrence of PTB. It
revealed that patients who had a previous history of TB
were significantly associated with developing smear positive PTB than those who did not have a previous history
of TB. Moreover, living with a TB patient had been one
of the most important predictors of smear positive PTB
in this study, which is consistent with previous findings
in Pakistan and India [17,20,28]. This might be due to
the fact that frequent contact with TB patients in a
household could lead to increased transmission of PTB.
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The duration of DM has been also associated with the
risk of developing smear positive PTB. Those patients
who have had DM for more than ten years had a higher
proportion of PTB than those who had shorter durations
(<5 years) of DM, which is consistent with a study done
by Jabbar et al. that showed a high prevalence of PTB
among diabetic patients who had DM for more than ten
years [21]. Uncontrolled high levels of blood glucose for
long periods of time could be another factor associated
with the development of TB. In addition, in low-resource
settings, early diagnosis and adequate glycemic control of
DM is difficult, and this will probably further increase the
proportion of diabetic patients developing TB.
In general, the present study and other studies carried
out so far show the high burden of PTB among the diabetic populations. Therefore, active screening and treatment of PTB among patients with DM is especially
relevant in TB-endemic countries, such as Ethiopia.
This study had some limitations. Direct smear microscope
alone may underestimate the prevalence of PTB in the study
population. We believe that comparing the prevalence of PTB
with non-diabetic patients to that of diabetic patients might
disclose important information about the occurrence of PTB.
However, due to financial constraints, we were unable to determine the prevalence of PTB among non-diabetic patients.
Selection bias may also arise from convenience sampling.
Conclusion
The overall prevalence of smear positive PBT among TB
suspected diabetic patients was high (6.2%) in Dessie. Pulmonary TB was occurring more often among patients with
DM (>10 years), and among patients who had high blood
glucose levels. Patients with a previous history of TB, history
of contact with TB patients in the family, living in urban
areas, and prolonged duration of DM were independent risk
factors for the occurrence of active PTB. Therefore, we recommend that, at the time of their diagnosis, diabetic patients
be screened for PTB and have regular check-ups. Further
studies are also recommended to strengthen and explore the
problem among diabetic patients in depth with large sample
sizes and advanced diagnostic techniques.
Additional file
Additional file 1: Multilingual abstracts in the six official working
languages of the United Nations.
Competing interests
There was no conflict of interest among the authors or with any other
parties.
Authors’ contributions
HA conceived, designed, and proposed the research idea. HA, AG, BA, and
BG were all involved in data collection, entry, clearance, analysis, and
interpretation of the findings. HA was responsible for drafting the
Page 7 of 8
manuscript. All authors were involved in reviewing the manuscript and
approving it for publication.
Acknowledgments
We would like to gratefully acknowledge the study participants who
provided us the sputum samples. Also, our sincere appreciation goes to all
the staff at the Dessie referral hospital for their kind support during the study
period.
Author details
1
Bahir Dar Regional Health Research Laboratory Center, Bahir Dar, Ethiopia.
2
Department of Medical Microbiology, School of Biomedical and Laboratory
Sciences, College of Medicine and Health Sciences, University of Gondar,
Gondar, Ethiopia.
Received: 9 January 2013 Accepted: 18 March 2013
Published: 27 March 2013
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doi:10.1186/2049-9957-2-6
Cite this article as: Amare et al.: Smear positive pulmonary tuberculosis
among diabetic patients at the Dessie referral hospital, Northeast
Ethiopia. Infectious Diseases of poverty 2013 2:6.
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